Bilateral bifid mandibular condyle: Report of a case with condylar fractures

Elif Tarim Ertas; Halil Sahman; Meral Yircali Atici

doi:10.4103/2321-3841.120127

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Year : 2013 | Volume : 1 | Issue : 2 | Page : 80-82

Bilateral bifid mandibular condyle: Report of a case with condylar fractures

Elif Tarim Ertas¹, Halil Sahman², Meral Yircali Atici¹
¹ Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Abant İzzet Baysal University, Isparta, Turkey
² Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Abant İzzet Baysal University, Isparta, Turkey, Faculty of Dentistry, İzmir Katip Çelebi University, İzmir, Turkey

Date of Web Publication

21-Oct-2013

Correspondence Address:
Elif Tarim Ertas
Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, İzmir Katip Çelebi University, İzmir
Turkey

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2321-3841.120127

Abstract

Bifid mandibular condyle is an uncommon anatomic variation with a varied etiology implicated with its development. It can be symptomatic or the majority of the cases are diagnosed incidentally during radiographic examination. Bifid mandibular condyle may have a developmental origin or may occur secondary to trauma. The purpose of this paper is to report a case with bilateral bifid mandibular condyles associated with a history of condylar fractures presented with computed tomography and panoramic radiography findings.

Keywords: Bifid mandibular condyle, condyle fracture, computed tomography, trauma

How to cite this article:
Ertas ET, Sahman H, Atici MY. Bilateral bifid mandibular condyle: Report of a case with condylar fractures. J Oral Maxillofac Radiol 2013;1:80-2

How to cite this URL:
Ertas ET, Sahman H, Atici MY. Bilateral bifid mandibular condyle: Report of a case with condylar fractures. J Oral Maxillofac Radiol [serial online] 2013 [cited 2023 Mar 24];1:80-2. Available from: https://www.joomr.org/text.asp?2013/1/2/80/120127

Introduction

Bifid mandibular condyle (BMC) is an uncommon anomaly that has a vertical depression or deep cleft in the center of the condylar head in the anteroposterior or mediolateral plane. ^[1] It may be developmental or acquired and usually the patients with BMC have no significant complaints or clinical features such as pain or dysfunction. ^[2],[3] In the literature, Hrdlicka (1941) is the first author who describes BMC in a case series of 21 skull specimens ^[4] and then Schier firstly in 1948 reported this condition in a living persons. ^[5] The condyle cleft into two parts and duplication of the condyle results into an appearance of a "double" or "bifid" condylar head with distinct or indistinct groove. BMC is more often unilateral, but sometimes it may be bilateral. ^[1],[6]

BMC has an unclear etiology and although it is generally associated with trauma, several factors like an obstructed blood supply or other embryopathy, developmental anomalies, condylar fracture, perinatal trauma and surgical condylectomy are cited as other possible factors. ^[1],[7] The misdirected muscle fibers ^[8] and the fibrous septa of vascular bodies can separate the condyle head while the developmental period. ^[9] and also infection, irradiation, teratogenic drug use and genetic variance may play a role on the etiology of BMC. ^[3]

Bifid condyle is usually found incidentally during routine radiographic examinations. But some patients may have signs and symptoms of temporomandibular dysfunction, including joint noises and pain. ^[1] The presence of BMC is not determined by age or gender and the findings are among ages of 3 to 67 years. ^[10]

In this report, a 5-year-old girl with bilateral BMCs due to the history of trauma was presented with computed tomography (CT) and panoramic radiography (PR) findings.

Case Report

A 5-year-old girl was referred to our clinic with the complaint of dental problems. From her medical anamnesis, due to a serious accident history (falling from third floor to hoist way) at the age of 2 and consecutive condyle operations, a panoramic examination was performed in order to evaluate the teeth and jaw bones. In the panoramic radiograph, bilateral BMC as a consequence of head trauma was detected [Figure 1]. Pre- and post-operative CT examinations were obtained from her medical records and the resulted symphysis and bilateral condylar fractures were treated with surgical operation using mini plaques and condylar relocation [Figure 2]. Post-operative CT images showed two distinct anterior and posterior heads of both condyles in the appearance of bilateral BMC [Figure 3].

Figure 1: Panoramic radiograph of the 5-year-old child showing bilateral bifid mandibular condyles

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Figure 2: a. 3D Reformatted image of the girl showing bilateral condylar fractures and symphysis fracture. b. 3D Reformatted image of the CT sections showing right condylar fracture. c. 3D Reformatted image of the CT sections showing left condylar fracture. d. Coronal view of the CT section showing bilateral condylar fractures

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Figure 3: a. Coronal view of the CT sections taken 1.5 year after postoperatively. b. 3D Reformatted images of the patient showing right bifid mandibular condyle occurred postoperatively. c. 3D reformatted images of the patient showing left bifid mandibular condyle occurred postoperatively

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In the extra-oral examination, there was no asymmetry on the face and in the clinical examination no objective symptom including limitation in the mouth opening, TMJ dysfunction, pain, sound, or asymmetry were observed. Similar to most BMC cases the patient was asymptomatic.

Discussion

Duplication of mandibular condyle is a rare anomaly and generally has unclear etiology. Szentpetery et al. observed 1882 cadaveric skulls and found the incidence of BMC to be 0.48%. ^[2],[11] We know that up till now only two epidemiological studies have been carried out on living subjects. In 2008, Menezes et al. and, in 2010, Miloðlu et al. examined panoramic radiographs and found the incidence of BMC to be 0.018% and 0.3% respectively in different populations. ^[12],[13] This high frequency shows that BMC is a more frequent condition since it is frequently discovered with the use of advanced techniques of radiography such as CT, CBCT, and MRI. ^[13],[14]

The exact etiology of BMC is generally unknown. ^{[2],[13],[15]} Two major etiologies play a role on BMC. ^[2] However, the most suitable theory depends on traumatic origin. ^[15] Thomason and Yusuf have suggested prior trauma as an etiology and they reported two cases of unilateral BMC after condylar fracture. ^[16] Antoniades et al. also presented unilateral BMC after a sagittal condylar fracture. ^[10] Sales et al. reported a case of BMC 4 years after condylar fracture. ^[7] Poswillo ^[17] and Walker ^[18] presented an animal study that BMC can result from trauma. And also minor trauma can affect the growth center of the condyle and may result in a variation such as BMC. ^[10],[15] The second theory is based on obstruction of blood supply and fibrous septa in embryologic period. ^[2] Blackwood stated that condylar cartilage can be divided by fibrous septa during early developmental period. ^[19] Also, Moffet et al. described developmental effects in BMC. ^[9] However, Gundlach found no evidence of fibrous septa in BMC cases. ^[8] In our case, there was a history of trauma and the bilateral BMCs occurred due to the condylar fractures.

The morphology of BMC may range from shallow groove to distinct condylar heads and the orientation may be in anteroposterior or mediolateral direction. ^{[2],[14],[19]} This orientation has been used a differentiating factor for etiology. The mediolateral position is related to a developmental cause while anteroposterior position has been associated with a traumatic event. ^[11] Szentpetery et al. suggested that condylar heads in the sagittal plane indicates the trauma and the heads in the coronal plane indicates the fibrous septa as the etiology. ^[20] Loh ^[21] and Wu ^[22] reported that this may be true for many cases. In this case report, the condylar heads were in the sagittal plane as shown in the figure and compatible with the finding of Szentpetery.

The majority of cases are detected during the routine imaging procedure. In most cases, symptoms like TMJ dysfunction and pain are not evident. ^[2] However, in some reports, BMC is associated with TMJ disorders like pain, sounds, and restricted mandibular movement. ^[15] Ankylosis and facial asymmetries have also been reported. ^{[23],[24],[25]} In our case, the patient had no clinical symptoms like most of the cases reported in the literature.

In general, panoramic and other conventional techniques are sufficient for diagnosis. But in symptomatic patients advanced imaging techniques may be necessary for treatment planning. ^[26] CT scan is the best choice for detection of BMC without superpositioning. ^[2],[26] However, because of excessive radiation in CT, clinicians should prefer CBCT techniques in TMJ examinations. In addition, MRI allows imaging the soft tissues and surrounding articular structures and this makes MRI the gold-standard technique for TMJ radiographies. ^[26]

67% of patients with BMC are asymptomatic. In symptomatic cases, the treatment depends on presenting complaints of patient. In the presence of articular derangement, occlusal splints and arthroscopic surgery should be a treatment choice. But articular ankylosis may need surgical condylectomy or arthroplasty. ^[2]

As a conclusion, BMC is a rare morphologic variation of condyle with generally an unknown etiology. In the present report, a 5-year-old girl was presented with bilateral BMCs occurred due to condylar fractures. The parents were informed about the changes in the condyles and long-term follow-up was recommended in case-potential subsequent clinical symptoms.

Acknowledgements

This case was presented in a poster presentation given at 13 ^th Congress of EADMFR, 13-16 June 2012, Leipzig, Germany

References

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Figures

[Figure 1], [Figure 2], [Figure 3]

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